Healthcare Provider Details

I. General information

NPI: 1891078796
Provider Name (Legal Business Name): LAURA SHALLENBERGER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA TEMPRINE PA-C

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 W BROAD ST
HAZLETON PA
18201-6108
US

IV. Provider business mailing address

PO BOX 1830
ALLENTOWN PA
18105-1830
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-6400
  • Fax: 570-453-2353
Mailing address:
  • Phone: 484-862-3313
  • Fax: 484-664-7659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberTMA052595
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: